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Perithyroidal masses in a young woman
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A 28-year-old nurse was referred for the evaluation of increasing numbers of perithyroidal masses. Six months before the visit, the patient complained of anterior neck pressure and intermittent problems with swallowing.
Her primary care doctor performed a neck CT scan that showed a mildly enlarged thyroid with homogeneous thyroid with a 1-cm mass located inferior to the right lobe of the thyroid. Several months later, she was referred to an otolaryngologist who performed an MRI scan that showed bilateral small nodes in the area of the submandibular glands and the jugular digastric area. None of the nodes reached the size criteria for pathological nodes. In addition, the MRI showed an enlarged homogeneous thyroid with three oval lesions located inferior to both lobes of the thyroid immediately lateral to the tracheoesophageal groove and medial to common carotid arteries (Figure 1). The largest mass below the thyroid on the left was 1.3 cm and on the right was 1.7 cm in length. The MRI characteristics were consistent with benign lymph nodes (Figure 2). The masses were hypointense compared with fat on T1-weight images; isointense or slightly hyperintense compared with fat on T2-weighted images; and hyperintense with suppression of the fat signal on short T1 inversion relaxation recovery (STIR).
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The woman was referred to the endocrinology clinic for further evaluation. She noted an anterior neck pressure and occasional globus sensation that she could not swallow either liquids or solid food, but she did not have any episodes of choking or regurgitation. During the past year, she had intermittent symptoms of anxiety, hand-shaking and palpitations. Weight increased 5 lb to 7 lb during the past 6 months. She had no prior history or family history of thyroid disease. She denied a history of head and neck radiation. Her mother had Hashimoto’s thyroiditis and was taking thyroid hormone replacement; there was no other autoimmune disease or thyroid cancer in her family.
Office ultrasound confirmed an enlarged hypoechoic, heterogeneous goiter with the right lobe measuring 2.3 × 1.8 × 5.6 cm and the left lobe measuring 1.8 × 1.5 × 4.8 cm. The thyroid had vigorous vascular flow by Doppler analysis throughout the entire gland with many tiny hypoechoic pseudonodules, consistent with chronic thyroiditis (Figures 3A, B), and multiple hypoechoic masses located separate and inferior to the right thyroid lobe (Figures 2C, D) and inferior to the left thyroid lobe. There were at least seven individual masses inferior to the right lobe, and three on the left. The largest mass measured 2 cm in length. The masses did not have a hyperechoic hilum, peripheral vascularity or microcalcifications (Figures 3C, D).
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Photos courtesy of: Stephanie L.
Lee, MD, PhD |
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Significant laboratory tests included positive thyroid autoantibodies: thyroid peroxidase (TPO) antibody 189 IU/mL (reference range <10 IU/mL); and thyroglobulin antibody 107 IU/mL (reference range <20 IU/mL). Other tests were within the reference range, including intact parathyroid hormone 23.5 pg/mL (reference range 10-80 pg/mL); calcium 9.5 mg/dL; phosphorus 3.6 mg/dL; thyroid-stimulating hormone 2.68 mIU/L (reference range 0.5-4 mIU/L); total triiodothyronine 154 ng/dL (reference range 90-180 ng/dL); free thyroxine 1.4 ng/dL (reference range 0.9-1.8 ng/dL); and 25-hydroxyvitamin D 31 nmol/L.
An ultrasound-guided fine-needle aspiration (FNA) biopsy of the largest 2-cm mass inferior to the right lobe of the thyroid was performed. It revealed numerous mature, small lymphocytes, consistent with a reactive lymph node. No thyroid follicular cells were seen. Wash-out of the FNA needle contained unmeasurable levels of intact parathyroid hormone and thyroglobulin. With time, her TSH remained in the upper part of the reference range, and the patient was adamant that she does not want to start levothyroxine therapy and will have regular testing to detect progression of hypothyroidism.
Possible etiologies of perithyroidal paratracheal solid masses include parathyroid adenoma and benign and malignant nodes of the thyroid (see Endocrine Today Imaging Analysis article from February 2009 here) and head and neck carcinomas.
Inflammatory thyroid disease, including Hashimoto’s thyroiditis, Graves’ disease and subacute thyroiditis, will often have a diffuse reduction in thyroid echogenicity. Mazziotti has described using the degree of hypoechoic change of the thyroid to predict hypothyroidism. In addition, thyroiditis is usually associated with diffuse hypervascularity, and recently paratracheal lymph nodes were described as a new sonographic finding by Serres-Créixams and colleagues in 2008. In a prospective study of 309 consecutive patients, 199 patients were categorized as having autoimmune thyroiditis with a positive TPO antibody test. Further, 184 of 199 in this group and 28 of 100 controls had paratracheal nodes (P<.001; sensitivity, 93.4%; specificity, 74.5%). Another report noted the frequent association of Hashimoto’s thyroiditis with single and multiple cervical nodes. FNA biopsy of 22 nodes showed benign hyperplasia.
Endocrinologists should be aware of the frequent finding of enlarged, reactive paratracheal and cervical nodes in patients with autoimmune thyroiditis, but other conditions, including metastatic nodes — especially from thyroid carcinoma and a parathyroid adenoma, should always be excluded when perithyroidal masses are seen.
Stephanie L. Lee, MD, PhD, is associate chief in the section of endocrinology, diabetes and nutrition and associate professor of medicine at Boston Medical Center. She is also an Endocrine Today Editorial Board member.
For more information:
- Mazziotti G. Clin Endocrinol (Oxf). 2003;59:223-229.
- Paksoy N. Acta Cytol. 2009;53:491-496.
- Serres-Créixams X. J Clin Ultrasound. 2008;36:418-421.
Disclosure: Dr. Lee reports no relevant financial disclosures.